Thursday, September 3, 2009

The public dialog surrounding health care has become fairly frustrating to me. There's a generation gap, an information gap, a comprehension gap, and not only that, but plenty of hypocrisy and misinformation going around.

First: No, the US health care system is not the best in the world. We may have the best experts on some diseases, and very good health care, but the overall quality of care, system-wide, is no better than tenth in the world. Even Forbes magazine - hardly a bastion of socialism - puts the US at 11th healthiest. In 2000, the WHO put the US health care system as 15th best - 37th accounting for how much we spend.

No matter what anecdotes Fox News, the Wall Street Journal op-ed pages, or anybody else spout about the horrors of socialized medicine, the fact of the matter is that nearly every serious look at the data tell us that Canada, the UK, Sweden, etc have far better health care systems.

Second: The US already has government-provided health care. For 2005, the WHO calculates total government spending on health care in the US at $2,862 per capita (out of a total of $6,350 - yes, both figures have risen substantially in the last 4 years). In other words, between Medicare, Medicaid, the Veteran's Administration, and other government provided insurance and health care systems, Uncle Sam pays directly for about 45% of all health care.

I don't believe that counts the employer tax break, which as an indirect subsidy amounts to about $500 per person, and Medicare spending has grown sharply in the last four years. Government insurance programs cover directly more than a quarter of the population directly, and the subsidies affect half the population.

The result of selectively covering the poor, elderly, and disabled is one of the most expensive (and least efficient) government health care systems in the developed world. The US government, in 2005, spent more money per capita on health care than the Canadian government, the German government, the UK government, the Swedish government, and most of the other European governments you hear about when people start talking about socialized medicine and universal health care.

Iceland, Switzerland, and Denmark's governments all spent more than Uncle Sam in 2005 - in nominal terms, but in terms of purchasing power parity (everything is more expensive there), they spent less than our government. Austria pretty much matches us in PPP terms; so far as I can tell, the French and Norwegian governments alone spent more money on health care than our government did.

So if "government provided health care" is a form of socialism ... ladies and gentlemen, I present to you the United States: The world's third or fourth most socialized medicine on the planet - and the only one in the top 20 that can't manage to cover all its citizens.

Third: The generation gap. What a lot of people don't seem to understand is that employer health benefits are on the downslide. And that matters a lot more for us young folk, who are part-timers, new hires whose contracts don't have grandfathered care, entrepreneurs, subcontractors, self-employed, and generally get the short end of the stick when it comes to government subsidies and government-provided coverage.

I'm 25. Mortality and disease and high health care bills are pretty uncommon in our age bracket - but there aren't many of us who don't realize that skimping on preventative care now will cost use when we're older, or that one accident, one unusual disease will completely wipe out our pocketbooks and put us in the hole. Not only that, but we probably won't even be able to get care until later in the course of a disease or long-term condition if we aren't covered, and that means it'll get a lot worse.

And so most of us are strongly in favor of health care reform. It's not surprising; we're right there. We can see our self-interest, and we can see our taxes fueling a system that spends enormously and inefficiently on everybody else. And when I hear about all the older folks hollering and protesting at "town hall" meetings about "socialized medicine," I can't help but think: There is someone who probably benefitted from government-subsidized health care for several decades of their life, and is probably covered directly by Medicare now.

And I think to myself that they are probably more than a little bit of a hypocrite. They have socialized medicine. They're probably afraid it'll get cut if the government stretches out to pay for everybody - something I think about a lot when I look at how older folk respond to intimations of Medicare cuts. Those young people, they don't need insurance, most of them are really healthy - so many of the older generation seems to think.

And who is going to be paying for this, paying for the growing national debt, paying for any health care reform? Most of today's retirees aren't going to be paying many taxes twenty or thirty years down the road. Most of today's young people will. So when I see members of the older generation fighting health care reform tooth and nail, I look at the demographics and the statistics and I think to myself that it looks like most of the protesters are engaging in an exercise in hypocrisy.

But back to the issure of young people needing coverage. Here we come to the comprehension gap. Because when it comes to having health care, it's do or die. And so when it comes to insurance, you need coverage that will handle a major emergency, which in a market where the government is paying for most of everybody else's ticket, in a market where you can't shop around between more than a handful of providers, in a market where bloated middlemen work hard to make their share larger, in a market with an enormous information gap, means that you're completely fucked if you're a little fish on your own shopping for coverage.

I happen to have gotten lucky in that my graduate school actually provides health coverage as part of my funding package, and it might even be adequate coverage in the event of a major medical emergency. I don't know yet. There's always a lot of fine print, and I haven't spent several weeks reviewing it - not that I could afford to buy adequate coverage on my graduate stipend. I don't exactly have a choice there.

So. That turned out to be a longer rant than I expected, and there's so much more I could talk about, but I'll leave you with the summary and the recap. First, other countries do actually have better health care systems. Second, the US government is already spending enough to provide universal coverage and better coverage. Third, your experience and understanding of this country's health care is going to vary radically based on age and socioeconomic background.

At the risk of sounding like a teenager, many of you making loud objections really just don't understand. The holes in the system are a lot more visible to those of us living in them, and to those who trip over and fall in one.